- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.74 / $1,093.00 / $1,093.00
| Professional | | $1,039.74 | $1,093.00 | $1,093.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.33 / $1,209.33 / $1,209.33
| Facility | | $1,209.33 | $1,209.33 | $1,209.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.94 / $1,088.41 / $1,209.33
| Professional | | $1,027.94 | $1,088.41 | $1,209.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.92 / $520.92 / $1,209.33
| Facility | | $520.92 | $520.92 | $1,209.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.94 / $1,209.33 / $2,004.12
| Professional | | $1,027.94 | $1,209.33 | $2,004.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.54 / $713.40 / $787.19
| Professional | | $594.54 | $713.40 | $787.19 |